Provide clinical leadership for utilization management programs, including prior authorization, concurrent review, retrospective review, and appeals.
Set UM strategy aligned with organizational goals for affordability, quality, member experience, and regulatory compliance.
Serve as senior clinical advisor to executive leadership on utilization trends, risk areas, and intervention opportunities.
Oversee the medical policy team, development and refinement of utilization management policies, protocols, and criteria based on nationally recognized standards (e.g., MCG, InterQual)
Lead the Medical Policy and Utilization Management Governance Committees
Medical Decision-Making & Oversight
Oversee complex and high-risk utilization review cases, including medical necessity determinations and claim reviews.
Conduct clinical reviews and/or oversee peer-to-peer reviews with ordering and attending providers.
Ensure consistent, evidence-based application of clinical guidelines and medical policy across all UM functions.
Provide clinical expertise to teams conducting coding, payment integrity, and reimbursement activities.
Contribute medical expertise to case management and care coordination processes, ensuring members transition to the appropriate level of care.
Provider & Stakeholder Engagement
Act as senior clinical UM liaison to network providers, facilities, and delegated UM partners.
Build and maintain strong physician relationships to support appropriate utilization, practice transformation, and quality improvement.
Represent Medical Management in cross-functional leadership forums (Quality, Network, Pharmacy, Population Health).
Program Performance & Improvement
Lead development and implementation of UM interventions that reduce unnecessary utilization while maintaining or improving quality outcomes, including strategies for integration of AI technologies to improve efficiency, accuracy of reviews, and user experience.
Review utilization data, denial patterns, appeals outcomes, and inter-rater reliability results to identify improvement opportunities and develop solutions for implementation and continuous quality improvement
Oversee performance and outcomes generated by contracted UM vendors
Ensure UM programs meet CMS, URAC, and state regulatory requirements.
Support workforce development, consistency of decision-making, and clinical calibration across UM teams.
Conduct and support training of medical directors and UM staff
Required Qualifications
Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
Board Certified by an American Board of Medical Specialties (ABMS) board.
Preferred current, unrestricted medical license in Nebraska. If not currently actively licensed in Nebraska, verification of attainment within 6 months of start.
10+ years of combined clinical practice and health care industry experience.
Demonstrated experience in utilization management, medical necessity review, and physician peer review
Demonstrated effective communication skills, a commitment to continuous improvement in healthcare delivery, and the ability to adapt to a dynamic and rapidly evolving healthcare environment
Requirements
Prior experience in a senior or enterprise-level UM leadership role.
Three + years Managed care ex
Benefits
Health insuranceRemote work options
Additional Information
At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.
Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there's no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you'll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.
The Senior Medical Director, Utilization Management is the physician leader accountable for strategic and operational leadership of utilization management (UM) programs across commercial, ACA, and/or Medicare Advantage lines of business. This role provides enterprise-level clinical leadership to ensure UM programs improve quality, appropriateness of care, provider collaboration, and total cost of care, while meeting regulatory, accreditation, and compliance standards.
This position serves as the senior clinical authority for UM policy, decision-making, and performance, and leads other Medical Directors and clinical staff engaged in utilization review, prior authorization, and medical necessity determinations.
Candidates applying to this position may be hybrid or remote and can live in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas. The candidate selected for this role will be required to visit the Omaha based job site for occasional strategic meetings throughout the year.
Nebraskablue · Omaha, NE